General. This chapter describes the mission, philosophy, policies, procedures, responsibilities, and guidelines of the Indian Health Service (IHS) Nutrition Program. It states the goal and objectives, standards, scope of program services, operating relationships, staffing criteria, and responsibilities to be followed in attaining and maintaining quality nutrition and dietetic services for American Indians and Alaska Natives (AI/AN). The Area office with approval by the Headquarters Nutrition and Dietetics Section may impose a change in a standard of this chapter where unique conditions justify such a change and minimum standards are met.

Mission. The goal of the Nutrition Program is to raise the nutritional health status of AI/ANs to the highest possible level. Nutrition Programs contribute to the attainment of the optimal health status of the population by reducing the risk of chronic diseases by bridging the gap between nutritional science and applying sound nutritional practices by community members.

Philosophy. The significance of nutrition throughout the life cycle is increasingly known and documented. Optimal nutrition ensures a sufficiency of all nutrients required for normal metabolic processes at all stages of human development and avoids excesses that can modify those metabolic processes and lead to pathologic changes. A state of poor nutrition contributes to or complicates a variety of diseases and disabilities. Many nutrition-related health problems among AI/ANs are associated with a number of factors including inadequate housing, poor sanitation, socioeconomic problems, low literacy skills, unhealthy lifestyle habits, and food supplies that are inadequate in variety or quantity.

Promotion of optimal nutrition and nutritional care are essential to a well-planned health program and are especially significant in quality health care for AI/ANs. Nutrition services that are consistent with needs, resources, cultural acceptability, and educational level of AI/ANs are most effective when family oriented and coordinated with other IHS and tribal programs.

Policy. It is the policy of the IHS Nutrition Program to:

Provide comprehensive nutrition and dietetic services that address preventive, therapeutic, and rehabilitative nutritional care of the highest possible quality within available resources.

Ensure that all IHS Nutrition Programs meet relevant accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Finance Administration (HCFA). In those program areas not addressed by JCAHO and/or HCFA standards or where more definitive professional standards do not exist, the IHS Nutrition Program adopts the standards of The American Dietetic Association (ADA) and the American Public Health Association (APHA). The IHS Nutrition Program develops standards based upon professional judgments for those areas in which no nationally recognized standards are available.

Ensure that quality nutrition care is provided by all IHS and tribally administered service units in the Area. The Area Nutrition Program staff ensures that Area Chief Medical Officers and Area Directors can meet their respective responsibilities for ensuring that quality health care is provided by Area Service Units.

Ensure the consistency of IHS publications with the established Department of Health and Human Services (HHS)/United States Department of Agriculture (USDA) dietary guidance principles. All dietary guidance publications prepared by IHS staff are scientifically accurate, culturally relevant, and meet the needs of the population served and have adhered to the IHS Circular No.90-4, Clearance of Publications on Dietary Guidance.

Ensure that the IHS Nutrition Programs are in full compliance with all written standards. When programs are not in full-compliance, a plan should be developed for implementing the standards and attaining the goal of full compliance.

Purpose of Standards. This chapter offers standards for the full range of IHS Nutrition Program services to ensure that AI/ANs receive the highest possible quality care. These standards provide a set of uniform practices for the operation of the IHS Nutrition Program. The standards do not preclude the use of additional or comparable standards by IHS or tribal Nutrition Programs especially in the interest of securing third-party funds.

Objectives. The IHS Nutrition Program is an integral part of the total IHS health care system. The objectives are:

To provide encouragement and guidance to AI/AN students interested in nutrition and dietetic careers.

To integrate nutrition and dietetic services into all applicable intervention programs and services in hospitals, nursing homes, residential substance abuse treatment centers, health centers, and communities served by the IHS.

To provide guidelines and standards as a basis for monitoring and evaluating nutrition and dietetic services for quality improvement.

To ensure continuity of nutrition care through coordination of nutrition and dietetic services among hospital, nursing home, residential substance abuse treatment center, clinic, and community programs.

To act as advocates for nutrition programs and issues that affect the health status of AI/ANs.

To provide encouragement and guidance to AI/AN individuals and communities in efforts to take responsibility for their own health.

To promote the acquisition of new knowledge to improve the nutritional status of AI/ANs through surveillance and limited research aimed at improving their health status and the health dietary system serving them.

Nutrition Functions. The IHS Nutrition Program addresses its mission, goal, and objectives through six general functions. These comprise an interrelated and interdependent system for the delivery of ambulatory patient care; public health nutrition; and hospital, nursing home, and residential treatment center dietetic services at the IHS Headquarters, Area, and Service Unit levels. These six functions are defined as follows:

Program Planning. Program planning encompasses a range of activities for providing comprehensive nutrition services. This includes participation with various IHS and tribal representatives to identify and assess problem areas, document areas of unmet need, and develop and carry out specific health plans. This planning includes participation in other government sponsored health and human services initiatives aimed at focusing attention on health and nutrition issues of national concern, e.g., prevention, intervention, treatment, and rehabilitation for the individual, family, and community.

Setting and Meeting Standards. Standard setting in the IHS Nutrition Program requires adherence to standards mandated or suggested by organizations such as the JCAHO, HCFA, ADA, APHA, requirements of the Federal Managers' Financial Integrity Act Public Law (P.L.) 97-255, and/or State licensure laws, and includes the development of Nutrition Program standards, standards of care, audit criteria, and reports applicable to the IHS.

Program Operations. Program operations encompass the delivery of a wide range of nutrition and dietetic services and activities that can be divided into three major subgroupings: patient services, community services, and administrative activities.

Patient services are offered to individuals, groups and families. These services include inpatient meal service, inpatient and outpatient treatment as well as field contacts and follow-up, and referrals to the health care providers.

Community services are based on assessed needs and requested actions from tribes/corporations.

Administrative activities are related to resource management; quality improvement; maintenance of activities and cost records; and development and implementation of agreements with tribal, State, and Federal agencies/institutions.

Monitoring and Performance Improvement. Monitoring programs improves quality, helps to ensure that AI/ANs receive the highest possible quality of care, ensures requirements for the IHS Nutrition Program are met, and ensures that the programs are in compliance with JCAHO, HCFA, ADA, APHA, Federal law, and IHS Standards.

Program Evaluation. Program evaluation ensures that the mission, goal, and objectives are achieved and the quality of nutrition and dietetic services provided are evaluated and result in the delivery of quality nutrition and dietetic services to AI/ANs. Program reviews will be performed through an annual assessment of the nutrition and dietetic services using on-site review reports, JCAHO and HCFA surveys, departmental nutrition and dietetic, IHS Nutrition Program reviews, IHS Resource Requirements Methodology (RRM), Resource and Patient Management System, Patient Care Component (PCC) reports, Nutrition and Dietetic Program Activity Reporting System (NDPARS), or other data reports. Program reviews identify strengths, deficiencies, and unmet needs to enable corrective actions.

Each Headquarter, Area and service unit nutritionist, dietitian, nutrition/dietetic technician, and food service supervisor must submit a quarterly narrative report (See Appendices 3-5-A and 3-5-B) and an NDPARS Form.

Service unit staff will submit one copy of the narrative report and two copies of the NDPARS Form to the IHS Area Branch/Section Chief or designee by the fifth working day of the month.

IHS Area Branch/Section Chief or designee summarizes the service unit narrative reports, reviews the NDPARS forms, and submits the area summary quarterly and one copy of each Area and service unit NDPARS Form to IHS Headquarters by the tenth working day of the month.

Headquarters staff will provide Area and service unit NDPARS feedback to the IHS Area Branch/Section Chief or designate at least quarterly.

Resource Management. Resource management includes the utilization of personnel, money, and materials to achieve the desired outcomes in the most efficient and effective manner possible.

All Nutrition Program professional staff delivering nutrition and dietetic services to AI/ANs must have the qualifications and experience as stated in the U.S. Office of Personnel Management's manual for Qualification Standards for General Schedule Positions, the 630 series, and be Registered by the Commission on Dietetic Registration of The American Dietetic Association.,/li>

Paraprofessional staff have the qualifications and experience required for their position and have supervision from qualified nutrition and dietetic staff.

The IHS RRM for nutrition and dietetic staff must be applied to all service sites to estimate personnel and resource requirements. The staff levels for service units and Areas must be aggregated to form Area and national budget estimates.

The Nutrition Program offers field experience and mentorship to graduate and undergraduate nutrition students as time, staff, and meaningful experience opportunities are available. When student training is provided, a collaborative agreement is developed between the educational institution and the program. The Nutrition Program seeks and encourages interested AI/AN students to enter the field of nutrition.

Training.

General. It will be the responsibility of the Area office and the facility to identify resources for training and to ensure completion of training of Nutrition Program staff for:

The acquisition of new skills/techniques.

The upgrading of knowledge and skills related to current trends in community, clinical, and administrative nutrition and dietetic practice.

Meeting identified personnel/program needs.

IHS Nutrition Program Orientation. All Nutrition Program professional staff must successfully complete the IHS Nutrition Program basic orientation. This provides an orientation to the IHS philosophy of nutrition care and training in skills needed to provide culturally-sensitive services.

3-5.2 ORGANIZATIONAL RESPONSIBILITY

These functions are delegated to ensure program continuity as follows:

Headquarters Functions. The Chief, Nutrition Section, IHS Headquarters, is responsible for the total IHS Nutrition Program and serves as the consultant and technical advisor to the Director of IHS and staff regarding the scope of the program IHS-wide, its operation, quality of services, priorities, and identification of unmet needs.

Program Planning

Analyzes and interprets IHS Nutrition Program activity data, Area reports and other data sources, and prepares an annual report.

Formulates program objectives or plans that meet specific national objectives, IHS-wide needs and service requirements, and that reflect the needs of local service populations communicated through Area and service unit Nutrition Programs.

Participates in Headquarters program planning activities and special planning projects.

Setting and Meeting Standards.

Reviews national standards for administrative, community, ambulatory, and inpatient nutritional services and professional practice and determines applicability for IHS Nutrition Program operation.

Develops the IHS-wide Nutrition Program standards and requirements in conjunction with Area section or branch chiefs.

Participates in development of IHS policies and procedures that affect nutrition programs.

Participates in the development of national nutritional standards, guidelines, and objectives.

Program Operations.

Provides technical assistance, information, and support services to IHS Director, Headquarters staff, and Area administrative and program staff.

Participates in the development of IHS policies that affect the health and well-being of AI/ANs.

Explains the scope of IHS Nutrition Program to tribal leaders, Indian organizations, governmental agencies, and professional groups.

Participates in the development of national policies that affect nutrition services.

Provides assistance to area counterparts and keeps them informed of national policies and legislation that impact on Area and service unit operations.

Maintains working relationships with national health and nutrition programs and collaborates in the development of interagency agreements.

Provides direction and supervision for the IHS Nutrition and Dietetic Training Program.

Represents the IHS and advocates for AI/ANs at governmental, national and State meetings and serves on IHS and other pertinent committees.

Develops scope of work, RRM, and other management tasks for IHS Nutrition Programs.

Encourages, coordinates, and conducts research aimed at improving the health of AI/ANs and the health delivery system serving them. Such research efforts are coordinated to ensure maximum gain in relevant knowledge and conservation of scarce resources while protecting the rights and well-being of research project participants. When appropriate, collaboration with other governmental agencies and interested parties is encouraged.

Monitoring and Performance Improvement.

Monitors the IHS Nutrition Program to ensure that the programs comply with IHS standards and requirements, i.e., JCAHO, HCFA, ADA, APHA, and Federal laws.

Documents findings and makes recommendations to correct IHS-wide, Area, or service unit deficiencies.

Program Evaluation.

Participates in Headquarters management reviews of IHS program operations and recommends change when necessary.

Conducts annual evaluations of the Nutrition Program operations through on-site visits, the review of manual issuances, reports, and other IHS data sources.

Resource Management.

Prepares budget proposal to ensure that adequate resources are available to meet Nutrition Program objectives.

Assists Area counterparts in the recruitment and retention of qualified nutrition and dietetic staff.

Works with Area counterparts in identifying training needs and training priorities. Assists Nutrition and Dietetic Training Program in planning and conducting training to meet the needs of staff and service population.

Assists Area counterparts in developing field experience, selecting, and placing nutrition and dietetic students. Selects and places Commissioned Officer Student Training Extern Program students. The Nutrition Program offers field experience and mentorship to graduate and undergraduate nutrition students as time, staff, and meaningful experience opportunities are available. When student training is provided, a collaborative agreement is developed between the educational institution and the program. The Nutrition Program seeks and encourages interested AI/AN students to enter the field of nutrition.

Area Functions. Area Nutrition Section/Branch Chiefs are responsible for the total Nutrition Program for their respective Area and serve as the consultants and technical advisors to the IHS Area Directors and staffs regarding the scope of the program Area-wide, its operations, quality of services, priorities, and identification of unmet needs.

Program Planning.

Analyzes and interprets data from Area-wide nutrition and dietetic reporting systems and other sources.

Participates in Area and service unit planning activities and develops annual Nutrition Program plans that are consistent with expressed needs of local service population and with national and Area priorities and objectives.

Develops Nutrition Program proposals in support of service area needs and requests.

Reviews national and IHS nutrition standards for nutritional care and professional practice and determines applicability for use Area-wide.

Develops Area-wide Nutrition Program requirements in conjunction with service unit/tribal staff.

Assists nutrition staff at the local level to develop service unit/tribal specific standards and protocols of care and other operational guidelines.

Reviews and updates with service unit staff, IHS nutrition standards for nutritional care and professional practice, the IHS-approved diet manual and care guidelines, and patient instructional materials.

Program Operations.

Provides technical assistance and support services to Area director and Area administrative and program staff.

Provides coordination for consultation to nutrition staff individually and collectively on program planning, operations, standards of care, performance improvement, evaluation, and management of available resources.

Participates in the development of IHS policies at the Headquarters and Area levels that improve health care and services.

Represents the Area and/or Nutrition Program at national, State, or local meetings and serves on IHS and other pertinent committees.

Develops and/or reviews the scope of work, and provides technical assistance and monitoring for IHS Contract Health Service (CHS), and tribal contracts for Nutrition Programs.

Area Branch/Section Chief or designee summarizes the service unit narrative reports, reviews the NDPARS forms, and submits the Area summary quarterly and one copy of each NDPARS form to Headquarters by the tenth working day of the month.

Develops annual training budget to request that adequate resources are provided for conducting workshops and special projects.

Provides consultation to service unit/tribal staff regarding recruitment and placement of nutrition students. The Nutrition Program offers field experience and mentorship to graduate and undergraduate nutrition students as time, staff, and meaningful experience opportunities are available. When student training is provided, a collaborative agreement is developed between the educational institution and the program. The Nutrition Program seeks and encourages interested AI/AN students to enter the field of nutrition.

Assists in orientation of new staff regarding IHS Nutrition Program.

Participates in planning for the construction and/or remodeling of facilities.

Assesses staffing and provides recommendations for staffing levels.

Service Unit Functions. Qualified nutritionist and/or dietitians are responsible for the service unit Nutrition Program. Nutritionists and/or dietitians serve as the consultants and technical advisors to the service unit/tribal health director and staff regarding the scope of the program service unit-wide, its operations, quality of services, priorities, and identification of unmet needs.

Prepares a comprehensive, annual nutrition program plan that is consistent with expressed needs of the local service population and with national, Area, and service unit priorities and objectives.

Setting and Meeting Standards.

Reviews national and IHS standards, operational procedures, and program guidelines from IHS and non-IHS health and nutrition agencies/institutes and assesses applicability for use locally. If the IHS standards are not applicable, tribal-specific standards are prepared and submitted to the IHS Area Nutrition Program for review.

Develops and reviews with Area nutrition and dietetic staff local policy and procedure issuances and nutrition care standards and guidance.

Reviews and updates the service unit nutrition program policy and procedure manual for administrative, community, inpatient, and outpatient services annually.

Reviews with Area nutrition staff the IHS-approved diet manual and nutrition care guidelines.

Provides technical assistance and support to the service unit director and administrative and program staff.

Supervises service unit nutrition and dietetic professional and paraprofessional staff.

Describes the scopes of the service unit Nutrition Program to local tribal leaders, program managers, and community agencies.

Maintains working relationships with local health and nutrition agencies to coordinate services.

Maintains familiarity with changes in legislation and IHS policies and regulations that impact on service delivery and patient care.

Implements policies, procedures, and nutrition guidelines.

Participates in the development of IHS procedures at the service unit level to improve the management and delivery of health care.

Represents the service unit and/or Nutrition Program at State or local meetings.

Serves on IHS and other pertinent committees.

Unites with other service unit nutritionists and dietitians and Area consultant/branch chiefs in Area-wide activities including strategic planning, cooperative development and use of programs and materials, peer program reviews, and networking.

Completes nutrition and dietetic audits as required by JCAHO and IHS standards.

Identifies opportunities to improve and provides the appropriate follow-up.

Program Evaluation.

Develops nutrition and dietetic performance improvement program that will comply with IHS, HCFA, JCAHO, and professional standards and requirements.

Conducts an evaluation of the service unit Nutrition Program using the results of nutrition and dietetics audits, on-site evaluations by Area nutrition and dietetic consultant, JCAHO survey team findings, and service population surveys/audits. Results of evaluations are reflected in future program plans.

Participates in HCFA, JCAHO, Area management, and peer reviews.

Resource Management.

Assesses and establishes manpower needs and identifies resources to meet them using IHS staffing document for nutrition services.

Reviews and updates position descriptions, billets, and performance standards in conjunction with area consultant.

Participates with Area counterparts in staff recruitment, placement, and retention.

Identifies training needs and deficiencies and develops a plan to meet needs.

Offers field experience and mentorship to graduate and undergraduate nutrition students as time, staff, and meaningful experience opportunities are available. When student training is provided, a collaborative agreement is developed between the educational institution and the program. The Nutrition Program seeks and encourages interested AI/AN students to enter the field of nutrition.

Participates in planning for the construction and/or remodeling of facilities.

General. The Nutrition Program provides comprehensive dietetic services as part of total patient care. Dietetic services are organized and directed by a qualified dietitian with at least an annual on-site review by the Area nutrition section/branch chief. Dietetic services contribute to the attainment of the optimal health status of the population by reducing the risk of chronic diseases by bridging the gap between nutritional science and applying sound nutritional practices by community members. Dietetic services comply with IHS regulations and manual issuances and JCAHO and HCFA standards.

Program Planning. Dietetic activities are conducted according to a written plan that is based on identified needs and available resources and is consistent with local traditions and culture. The plan is reviewed and updated as necessary, but at least annually and approved by appropriate administrative personnel. Program planning includes at least the following:

Long-range objectives with measurable outcomes consistent with local program priorities, health and nutritional status of populations, national health objectives, Area and service unit strategic plans, and applicable legislation.

Intermediate and short-range objectives with measurable outcomes that are short-range and practical in scope and will lead to achievement of long-term objectives over time. Shorter term process objectives are essential to ensure progress toward longer term health outcome objectives.

Strategies, interventions, and methods designed to achieve objectives.

Description of resources needed to achieve program mission and objectives.

Evaluation plans describing what indicators of change will be evaluated and measured, what data will be collected, how data will be collected and analyzed, who is responsible, and how information will be used.

Evidence that Nutrition Program staff, community members, and collaborating organizations participate in the planning process.

Setting and Meeting Standards. Written dietetic service policies and procedures are developed in cooperation with the public health nutrition service and other appropriate hospital and clinic staff. Standard setting in the IHS Nutrition Program requires adherence to standards mandated or suggested by national organizations such as the JCAHO, HCFA, ADA, APHA, requirements of the Federal Managers' Financial Integrity Act (P.L. 97-255), dietary standards or guidelines of the HHS and USDA, and/or state licensure laws, and includes the development of Nutrition Programs standards, standards of care, audit criteria, and reports applicable to the IHS.

Policies and procedures are available to appropriate staff, reviewed and updated at least annually, and maintained for dietetic and food service administration in at least the following areas:

Dietetic Administration. The administrative policies and procedures include at a minimum:

Scope of work adequate for accreditation and contracting services.

Responsibilities and authority of the director of dietetic services or consultant dietitian (if the director is not a dietitian).

Employee management.

Performance appraisals.

Staffing patterns and scheduling.

Union agreements.

Orientation; inservice education, and training.

Performance improvement.

System to ensure all nutrition education materials are developed and approved as required by Area Dietary Guidance Policy.

Training for students, including extent of their involvement in patient care activities.

Food service administration.

Meal hours, tray service, cafeteria service, and vending machine(s).

Diet orders.

Menu planning.

Inventory and food procurement.

Food preparation.

Storage of food and non-food items.

Nutrition and food cost accounting.

Schedule of staff training.

Collaborative agreements, liaison, or cooperative activities with other organizations or agencies.

Disaster plan - internal and external.

Fire, safety, sanitation, and infection control.

Clinical Nutrition Care - Policies for inpatient and ambulatory. Nutrition care include at a minimum:

Scope of nutrition services and patient priorities.

Use of IHS Diet Manual or other approved diet manual and other reliable references.

Use of IHS Nutrition Care Guidelines or other approved nutritional care guidelines./li>

Meal Service. The characteristics of the food served is often what the patient remembers most about his/her hospitalization. Food is important to the healing process as well as to provide a sense of comfort, nurturance, and well being. Meals served are appropriate to the culture and tradition and medical diagnosis.

Patient Meals. Patients meals include all meals, infant formulas, and tube feedings served to patients.

Patients on oral intake receive at least three meals daily with not more than a 14-hour (HCFA 14 hours, JCAHO 15 hours) span between a substantial evening meal and the first substantial meal of the next day.

Systems that ensure each patient receives the correct tray and diet.

Dietetic personnel are responsible for delivering trays to the nursing units.

Nursing or dietetic service personnel may be responsible for serving trays to patients; hospital policy will determine this responsibility.

Tray service for patients in isolation is carried out in accordance with the Service Unit Infection Control Committee policies.

In hospitals with patient dining facilities, ambulatory and wheelchair patients are encouraged to eat in the dining room.

Other Meals. The provisions regarding subsistence to IHS employees and guests at American Indian and Alaska Native hospitals and residential treatment centers include:

When adequate hospital meal service facilities and food service staff are available, each IHS Area Director (or Service Unit Director if so designated) may authorize the sale of meals to hospital employees and guests and must approve Area/Service Unit rates for meals. The rates will be reviewed and adjusted as necessary every other year.

Charges for full meal rate will be based on an appropriate proportion of the complete aggregate cost of the meal and include the full cost of raw food, supplies, freight, and at least 1 percent of labor. If additional food service staff are required to prepare employee meals, then the labor percentage included in the cost will be increased proportionately.

For A La Carte rates facilities may establish individual prices for a la carte items offered to employees and guests in the cafeteria. The total price of an equivalent a la carte meal (entree, salad or soup, vegetable, dessert, bread, and beverage) must not be lower than the price of the Area/Service Unit Full Meal Rate.

The foregoing policies are applicable to food handlers except that they also will be required to take and pay for at least one meal a day unless the official delegated the authority for provision of subsistence and laundry services determines that there are adequate administrative controls to ensure full reimbursement for all food consumed. Food handlers will include all dietetic personnel and other personnel engaged in the preparation or serving of meals and those who have access to food for personal consumption.,/li>

The annual rate for full subsistence (three meals a day, 7 days a week) for employees furnished meals on a payroll deduction basis will be established on the basis of the complete aggregate cost of the meals furnished employees for 11 months. A proportionate charge will be made when employees take less than full subsistence on a payroll deduction basis. Therefore, no refund or credit for meals not taken during periods of annual or sick leave will be allowed except when an employee is on sick leave, or annual leave in lieu of sick leave, for more than 10 consecutive working days. In this case, credit for meals not taken will start on the eleventh day. Failure of an employee to take the meals to which she or he is entitled on one day will not entitle her/him to extra meals on any other day. No deduction for subsistence will be made from lump sum payments for accumulated annual leave.

Employees without a payroll deduction may purchase meals if allowed by Area/service unit policy. Payroll deductions and cash collected at IHS facilities must be retained by the Service pursuant to P. L. 103-332, Appropriations Act for the Department of Interior and Related Agencies for fiscal year ending September 30, 1995, and for other purposes.

The dietitian or designee receives from the administrative officer a monthly list of personnel authorized to utilize hospital dining facilities with payment for meals through payroll deduction or meal tickets. The dietitian or designee also receives prompt notice of list changes within the month.

Internal controls are established to ensure that only authorized personnel are served.

Authorized guest meals are served only where the food service staff is sufficient and dining room space is adequate to provide this service.

Dietitian or designee is notified at least 2 hours prior to single guest meal service and at least 48 hours prior to guest meal service for groups.

The administrative officer establishes procedures for issuing and selling guest and personnel meal tickets at all times including evenings, weekends, and holidays; dietetic service staffs neither sell meal tickets nor handle money for meals.

Collected, used guest meal tickets are returned to the hospital or Area accounting officer according to hospital/Area policies.

Persons who may receive free meal tickets include detained outpatients unable to pay, one relative of a critically ill patient as authorized by the physician, one parent of a pediatric patient who is breast feeding or assisting in the care of the patient, a discharged patient awaiting transportation, patient escorts in transit, Federal personnel in travel status on reduced per diem; guards for hospital prisoners, and selected volunteers.

Any person not listed above is required to purchase meal tickets; these include overtime or extended shift employees; persons who must eat because of emergency situations such as flood, tornado, power failure or fire; and Area office personnel on reduced per diem.

Non-patient Special Events. No food or beverage for coffee breaks and special occasions are provided from hospital subsistence.

Meal Planning and Preparation.

Culturally appropriate menus are planned for all age groups consistent with IHS Diet Manual or other IHS approved diet manual requirements, in accordance with current Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, and in accordance with the Dietary Guidelines for Americans. Meals provided to patients are prepared under safe and sanitary conditions, attractively served, palatable, nutritionally adequate, therapeutically correct, and culturally appropriate.

Cycle menus are planned, posted, and followed. Menu substitutions are appropriate, documented, initialed, dated on the menu form or calendar, and kept on file for 6 months.

Patients on oral intake receive at least three meals daily with not more that a 14-hour span between a substantial evening meal and the first substantial meal of the next day.

Patients not receiving oral intake are identified and monitored.

Only authorized persons are served meals.

No food or beverage for coffee breaks or other occasions are provided from hospital subsistence.

Food, disposable products, and cleaning supplies are prepared and stored in accordance with IHS Institutional Sanitation Guidelines, USDA and Food and Drug Administration temperature control standards, Public Health Services (PHS)/FDA Food Service Sanitation Manual, and the Occupational Safety and Health Administration. Only food service subsistence items are stored in refrigerators, freezers, and areas assigned to the Nutrition Program. All are properly stored, wrapped, and labeled.

Employee health policies for the Dietetic Program personnel are in compliance with Federal, State, and local laws and regulations.

Equipment is used for keeping perishable foods at safe temperatures during preparation, holding, delivery, and service to patient or client.

Procurement.

All foods, including donated foods, meet specification requirements of the Federal Hospital Subsistence Guide and are procured from sources considered satisfactory by a qualified food inspector.

Spoiled, adulterated, misbranded, or outdated food is reported to the dietitian and/or sanitarian for appropriate credit and disposal.

Safety and Sanitation.<

Food service sanitation surveys are conducted at least semiannually by the IHS Environmental Health Office (Indian Health Manual, Part 3, Chapter 11, Environmental Health). The dietitian or designee receives a written report of each inspection and submits a written reply to the hospital administrative officer stating corrective actions taken. Unsatisfactory reports require a follow-up within the next 10 weeks. The dietitian or designee will conduct regularly scheduled sanitation inspections.

Sanitation and safety control measures are maintained, and facilities and equipment are in compliance with laws and regulations.

Only authorized personnel enter receiving, storage, preparation, and service areas.

No food or beverage is consumed in the receiving, storage, preparation, and service area. IHS has a smoke-free policy; in non-IHS facilities tobacco use should be prohibited in receiving, storage, preparation, and service areas.

Cleaning schedules are developed, posted, and followed.

Equipment is adequate and appropriate and meets existing National Sanitation Foundation Standards.

Medical Nutrition Therapy. Nutrition care services are consistent with professional standards of practice. The dietitian provides nutrition assessment and counseling for inpatients and ambulatory care patients. If the ambulatory care clinic nutrition professional staffing levels are insufficient to meet service needs or are not justified on the basis of population size, patient care is provided by hospital and community dietitians and public health nutritionists as specified in a written plan.

Nutrition Screen. All patients are screened within 48 hours by the dietitian or designee and information pertinent to the feeding of the patient is collected and transmitted to the-food preparation area. Pertinent information includes:

Appetite.

Food allergies and/or intolerance.

Diet prior to admission.

Eating or feeding problems.

Personal and cultural food preferences and dislikes.

Diet order.

Diet Order. All patients have a diet order written by a physician and communicated to the Nutrition Program. Confirmation of phoned-in diet order is documented in the medical record by the physician within 24 hours.

Nutrition Assessment. There is evidence of timely and periodic assessment of the nutrient intake and tolerance to the diet ordered, and improvements in pertinent outcome data (e.g. behavioral, anthropometric, and biomedical indicators).

Nutrition Care Plans. Care plans are completed and include a summary of the dietary history, nutritional assessment, patient education and patient goals, description of handouts given, and assessment of patient's understanding of diet.

Documentation. A problem-oriented method of documentation {i.e., Subjective, Objective, Assessment, Plan (SOAP) or Problem, Intervention, Evaluation (PIE)} is used in the patient's medical record. The IHS Form 806 or equivalent PCC form is completed, dated, and signed by the registered dietitian.

Discharge Planning and Referrals. Discharge planning and appropriate referrals are made for follow-up. A copy of diet information is forwarded to referral agencies.

Equipment. Clinical equipment used for nutrition assessment is adequate, well maintained, and calibrated at least annually.

Patient Education. Nutrition education is an integral part of individual and group contacts and is an on-going part of the program.

Nutrition education provided is consistent with written outcome objectives that are behavioral and measurable.

The learner achievement of the educational objective is assessed and documented.

Nutrition classes are integrated with other health education classes.

Education and consultation are provided to other staff.

Accurate and appropriate nutrition education materials are utilized by all staff.

Adequate facilities are available for counseling and classes and equipment storage.

Performance Improvement. Dietetic services are adequate, appropriate, and of the highest possible quality. Services are monitored and improved. Problems are identified and resolved.

Written Plan. There is a written plan for monitoring, evaluating, and improving the quality and appropriateness of dietetic services. This plan includes objectives, responsibilities, scope of services, important aspects of services, indicators, and outcomes.

Coordination. In coordination with other departments, the director of the dietetic services is responsible for implementing the performance improvement process.

Service Improvement. Quality and appropriateness of services are monitored, evaluated, and improved through:

Routine and systematic collection of data about important aspects of dietetic service indicators that are monitored.

Data is periodically analyzed in order to identify opportunities to improve care.

When opportunities to improve care are identified, actions are taken, and the effectiveness of the actions are evaluated.

The performance improvement process reflects current knowledge, objective criteria, and written standards of care.

The performance improvement actions and findings are documented and reported.

As a part of the annual appraisal of the facility's performance improvement program, the effectiveness of the monitoring, evaluation, and care improvement activities (both clinical and administrative) are evaluated.

Contract Services. When an outside source provides dietetic services, the administrative officer is responsible for ensuring that the quality and appropriateness of services are monitored, evaluated, and improved as specified in a written plan.

3-5-4 PUBLIC HEALTH NUTRITION SERVICES

General. The focus of public health nutrition services is the health of the community. Public health nutrition services contribute to the attainment of the optimal health status of a population by improving nutritional status and reducing the risk of chronic diseases by bridging the gap between nutritional science and by applying sound nutritional practices by community members.

The IHS Nutrition Program provides public health nutrition service primarily in community and/or ambulatory care settings for populations of varying size and description. These services are provided by public health nutritionists, and community dietitians as assisted by trained paraprofessionals.

The following are basic to the IHS practice of public health nutrition:

Optimum nutrition is necessary for optimum health.

AI/AN community members have the right and responsibility to participate in developing community nutrition programs.

Public health nutrition service is interdependent and interwoven with the programs of AI/AN communities and public and private agencies.

AI/AN cultural traditions and values affecting the delivery of nutrition services should be promoted to the fullest extent possible.

Individuals and communities have primary responsibility for their own health and health care.

Planning. Public health nutrition activities are conducted according to a written plan that is based on identified needs and available resources. Nutrition activities and interventions are consistent with traditions and culture, service unit, Area, and national strategic plans, departmental and program scopes of service and contribute to improved health. The plan is approved by appropriate administrative personnel, reviewed and updated as necessary, but at least annually.

Agency, service unit, and Nutrition Program organizational charts.,/li>

Where nutrition services are provided and who provides these services.

Program deficiencies and needs previously identified.

Program mission, goal, objectives, and priorities and resources available.

Public Health Nutrition Service Plan. The plan includes at a minimum:

Priorities and objectives that accurately reflect nutrition and health status, chronic disease risk factors, important health problems and issues, community needs, and program deficiencies.

Long-range objectives with measurable outcomes consistent with local program priorities, health and nutritional status of populations, national health objectives, Area and service unit strategic plans, and applicable legislation.

Intermediate and short-range objectives with measurable outcomes that are short-range and practical in scope and will lead to achievement of long-term objectives over time. Shorter term process objectives are essential to ensure progress toward longer term health outcome objectives.

Culturally appropriate strategies, interventions, and methods designed to achieve objectives.

Description of resources needed to achieve program mission and objectives.

Evaluation plans describing what indicators of change will be evaluated and measured, what data will be collected, how data will be collected and analyzed, who is responsible, and how information will be used.

Evidence that Nutrician Program staff, community members, and collaborating organizations participate in the planning process.

Service Operations. Public Health nutrition services are planned, implemented, and evaluated in a manner consistent with standards of professional practice. Public health nutrition staff:

Provides services according to approved program plan or program plan amendments.

Provides services to organizations outside the IHS according to a written agreement or plan that details objectives to be achieved, resources to be used, and timeframes for completing activities, projects, or services.

Uses a variety of methods to promote sound nutrition practices in the community. The staff:

Promotes community awareness of nutrition-related health problems and issues through screening and educational activities.

Promotes, facilitates, and supports community-led nutrition intervention programs and other efforts that demonstrate individual and community responsibility for the health of tribal members.

Participates as a leader, liaison, or technical advisor in organized community partnerships using educational, environmental, and social change strategies to improve nutritional status.

Develops and implements community-based interventions designed to reduce the risk of chronic diseases and to improve nutritional status.

Collaborates and participates in development, implementation, and publication of local, area, and national nutrition program research (including data collection, analysis, and use) to determine disease prevalence, measure changes in health status, and evaluate programs.

Establishes and maintains referral systems.

Advocates for resources needed to maintain or improve community nutrition practices.

Develops or adapts community-specific public information and educational materials such as public service announcements, displays, newsletters, handouts, films, audiovisual resources, and posters.

Develops or adapts community-specific training materials for health, education, and social service agency staff (professionals and paraprofessionals).

Advocates for and monitors ordinances or legislation pertinent to nutritional problems of service population.

Direct Patient Care. Direct patient care (medical nutrition therapy) is provided by the public health nutritionist in accordance with policies and procedures delineated in this manual chapter under "Ambulatory Nutrition Services" (see section 3-5.5). If the ambulatory care clinic nutrition professional staffing levels are insufficient to meet service needs or are not justified on the basis of population size, patient care is provided by hospital and community dietitians and public health nutritionists as specified in a written plan. Direct patient care may be provided:

In the ambulatory care clinic.

Outside the ambulatory clinic in exceptional cases when compliance and continuity of care will benefit.

Training. The nutritionist offers training in nutrition to staff of IHS and other agencies or tribal programs. This ensures that the service population receives accurate and consistent information and promotes continuity of service.

The nutritionist should collaborate with the hospital dietitian in the service unit.

Coordination and Consultation. The scope of the public health nutrition service includes participating in health promotion and disease prevention activities, maintaining a liaison relationship with appropriate groups, providing technical assistance and consultation. If sufficiently staffed, the public health nutritionist will serve as a resource for staff in the service unit and other community organizations.

Food Assistance Programs of the US Department of Agriculture (USDA). The USDA Food Distribution Program on Indian Reservations the Food Stamp Program, and the Special Supplemental Food Program for Women, Infants, and Children (WIC), the Child and Adult Care Feeding Program, and School Feeding Program require or recommend nutrition education in regulations governing these programs. The IHS nutritionists coordinate services with such programs locally; however, the USDA has ultimate responsibility for the nutritional services provided. Therefore, IHS nutritionists' services should be limited to the following:

Training for program aides.

Referral of staff to the IHS Nutrition and Dietetics Training Program for training when applicable.

Site visits to provide services as defined in written program agreements and/or program plan.

Promotion of accurate and consistent nutrition information through work with program staff to develop new materials or identify or adapt existing materials.

Referral of individuals for USDA program services.

Liaison between such programs and the service unit.

Congregate Meal Service Programs. Congregate and family day care, Head Start, Senior Centers (Administration on Aging, Title III and IV), school lunch, residential substance abuse treatment centers, tribal jails, tribal nursing homes, Bureau of Indian Affairs school dormitories, and other tribal domiciliary care programs all serve AI/AN and off opportunity for nutrition education, food service management consultation, and training. The IHS intuitionalists offer assistance to staff and clients through liaison, consultation, coordination, and referral.

Comprehensive School Health Education. Nutritionist provides technical assistance in development and dissemination of nutrition components of comprehensive school health education programs and information on existing nutrition programs and resources.

Community Organizations and Groups. Parent-teacher organizations, local nutrition councils, Head Start boards, homemaker clubs, weight control and exercise groups, parenting groups, church groups, and other similar groups provide opportunities for nutrition education and discussion of nutrition issues affecting the community.

Other Agencies. Nutritionists participate in interdisciplinary and interagency networks, committees, and task forces that, promote or facilitate achievement of nutrition program objectives and contribute to the improvement of health and nutritional status of the population.

Contract Organization. Service unit agreements and contracts for nutrition services follow agency IHS regulations, standards, and guidelines. The Public Health Nutrition Program provides leadership and technical assistance in the development, implementation, and monitoring of these agreements and contracts.

Administration and Management. Personnel, financial, and other resources are sufficient to carry out the approved public health nutrition service plan for improving health and nutritional status of the population served.

Professional, paraprofessional, and support staff are available in numbers adequate to carry out program functions and mission.

The organizational chart is approved and reflects administrative structure.

A budget is written and approved and includes adequate funding for personnel, travel, training, equipment, and supplies, and is monitored on an ongoing basis, but not less than quarterly. Expenditures are maintained within budgetary limits.

Public health nutrition service office, counseling, and education space are adequate.

Services are documented with accurate and complete records that support timely preparation and submission of required reports including:

NDPARS.

Narrative.

Consultant reports required by contract or purchase oeders.

Setting and Meeting Standards. Standard setting in the IHS Nutrition Program requires adherence to standards mandated or suggested by national professional organizations such as the JCAHO, HCFA, ADA, APHA, requirements of the Federal Managers' Financial Integrity Act (P.L. 97-255), and/or State licensure laws, and includes the development of Nutrition Program standards, standards of care, audit criteria, and reports to the IHS.

Written public health nutrition policies and procedures are developed in cooperation with other appropriate hospital, clinic, and community program staff and include:

Public Health Nutrition Administration. The administrative policies and procedures include at a minimum:

Scope of public health nutrition services including description of liaison and consultative activities available to other agencies such as State and local health departments or other community agencies.

Format for written agreements to provide consultation and technical assistance to tribal programs and other agencies.

Planning and scheduling of staff orientation and training.

Use of Amendments to Health Care Improvement Act (P.L. 102-573) objectives and other reliable public health nutrition references.

Review criteria and process for educational materials used by all staff.

All applicable Internal Review Board, research clearance policies and procedures.

Fire, safety, and sanitation.

Clinical Nutrition Care. Direct patient care in the ambulatory care clinic may be provided as specified in a written plan. If services are provided in the ambulatory care clinic, policies include at a minimum:

Criteria and procedures to be followed for making and receiving nutrition referrals.

Criteria and procedures to be followed for nutrition follow-up visits.

Nutrition clinic schedule and scheduling procedures.

Use of IHS Diet Manual or other approved diet manual and other reliable references.

Use of IHS Nutrition Care Guidelines or other approved nutritional guidelines or standards of care.

Nutrition care process that includes a diet history, nutrition assessment, nutrition care plan, education or other intervention, and evaluation.

Documentation in medical record.

Performance Improvement. Public health nutrition services are appropriate and of the highest possible quality. Services are monitored and improved. Problems are identified and resolved.

Written Plan. There is a written plan for monitoring, evaluating, and improving the quality and appropriateness of public health nutrition services. This plan includes objectives, responsibilities, scope of services, important aspects of services, indicators, and outcomes.

Coordination. In coordination with other departments, the director of the public health nutrition service is responsible for implementing the performance improvement process.

Service Improvement. Quality and appropriateness of services are monitored, evaluated, and improved through:

Routine and systematic collection of data about important aspects of public health nutrition service indicators that are monitored.

Data is periodically analyzed in order to identify opportunities to improve care.

When opportunities to improve care are identified, actions are taken, and the effectiveness of the actions are evaluated.

The performance improvement process reflects current knowledge, objective criteria, and written standards of care.

The performance improvement actions and findings are documented and reported.

As a part of the annual reappraisal of the service unit's performance improvement program, the effectiveness of the monitoring, evaluation, and care improvement activities, (clinical, community, and administrative) are evaluated.

Contract Services. When an outside source provides public health nutrition services, the administrative officer is responsible for ensuring that the quality and appropriateness of services are monitored, evaluated, and improved as specified in a written plan.

3-5-5 AMBULATORY NUTRITION SERVICES

General. Ambulatory patient care nutrition services are planned and directed by a qualified dietitian or public health nutritionist.

Purposes. The purposes of ambulatory nutrition services are to:

Promote sound nutritional practices throughout the life cycle by individuals, families, and groups to improve health, to prevent potential health problems, and to provide medical nutrition therapy for patients with existing acute or chronic diseases.

Integrate nutrition interventions with medical and interdisciplinary support services in outpatient clinics and health centers, field health clinics, health stations, and school clinics. Dietitians and/or nutritionists participate as members of the health care team.

Ambulatory Nutrition Service Plan. In service units with both dietetic and public health nutrition services, ambulatory patient care services are planned cooperatively, carried out, and evaluated as specified in a written agreement that outlines roles and responsibilities. The ambulatory patient care services will be included in relevant sections of the dietetic and public health nutrition service plans and be consistent with the external and internal needs assessments of the facility and community.

Nutrition Intervention.

All patients are screened to determine the need for intervention.

Nutrition counseling is provided to patients and/or family members individually or in groups.

Nutrition therapy is consistent with findings of nutrition assessments, IHS or other approved professional nutrition care standards and guidelines, and written orders from the practitioner.

Using a problem-oriented method of documentation (i.e., SOAP or PIE) proceedings and results of nutritional care are documented in the medical record. The IHS Form 806 (or equivalent PCC form) is completed, dated, and signed by the registered dietitian.

Written documentation includes:

Nutrition assessment.

Nutrition care plan.

Description to nutrition intervention to include:

Summary of education and counseling provided.

Title of materials used or handouts given.

Assessment of patient's understanding of the care plan and goals set during the session.

Adjustments made to accommodate cultural and/or language needs.

Evaluation of the previous care plan on follow-up visits and revision as needed.

Evidence of continuity of care by Nutrition Program staff and other providers.

Timely and periodic evaluation of the results of care are provided and include: